Efficacy of Concurrent Chemoradiotherapy With S-1 vs Radiotherapy Alone for Older Patients With Esophageal Cancer
Yongling JiXianghui DuWeiguo ZhuYanguang YangJun MaLi ZhangJiancheng LiHua TaoJianhong XiaHaihua YangJin HuangYong BaoDexi DuDegan LiuXiusheng WangChaoming LiXinmei YangMing ZengZhigang LiuWen ZhengJuan PuJun ChenWangyuan HuPeijing LiJin WangYujin XuXiao ZhengJianxiang ChenWanwei WangGuangzhou TaoJing CaiJizhong ZhaoJun ZhuMing JiangYan YanGuoping XuShanshan BuBinbin SongKe XieShan HuangYuanda ZhengLiming ShengXiaojing LaiYing ChenLei ChengXiao HuWenhao JiMin FangYue KongXiaofu YuHuizhang LiRunhua LiLei ShiWei ShenChaonan ZhuJunwei LvRong HuangHan HeMing Chen
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Abstract:
Importance
Most older patients with esophageal cancer cannot complete the standard concurrent chemoradiotherapy (CCRT). An effective and tolerable chemoradiotherapy regimen for older patients is needed.Objective
To evaluate the efficacy and toxic effects of CCRT with S-1 vs radiotherapy (RT) alone in older patients with esophageal cancer.Design, Setting, and Participants
A randomized, open-label, phase 3 clinical trial was conducted at 23 Chinese centers between June 1, 2016, and August 31, 2018. The study enrolled 298 patients aged 70 to 85 years. Eligible participants had histologically confirmed esophageal cancer, stage IB to IVB disease based on the 6th edition of the American Joint Committee on Cancer (stage IVB: only metastasis to the supraclavicular/celiac lymph nodes) and an Eastern Cooperative Oncology Group performance status of 0 to 1. Data analysis was performed from August 1, 2020, to March 10, 2021.Interventions
Patients were stratified according to age (<80 vs ≥80 years) and tumor length (<5 vs ≥5 cm) and randomly assigned (1:1) to receive either CCRT with S-1 or RT alone.Main Outcomes and Measures
The primary end point was the 2-year overall survival rate using intention-to-treat analysis.Results
Of the 298 patients enrolled, 180 (60.4%) were men. The median age was 77 (interquartile range, 74-79) years in the CCRT group and 77 (interquartile range, 74-80) years in the RT alone group. A total of 151 patients (50.7%) had stage III or IV disease. The CCRT group had a significantly higher complete response rate than the RT group (41.6% vs 26.8%;P = .007). Surviving patients had a median follow-up of 33.9 months (interquartile range: 28.5-38.2 months), and the CCRT group had a significantly higher 2-year overall survival rate (53.2% vs 35.8%; hazard ratio, 0.63; 95% CI, 0.47-0.85;P = .002). There were no significant differences in the incidence of grade 3 or higher toxic effects between the CCRT and RT groups except that grade 3 or higher leukopenia occurred in more patients in the CCRT group (9.5% vs 2.7%;P = .01). Treatment-related deaths were observed in 3 patients (2.0%) in the CCRT group and 4 patients (2.7%) in the RT group.Conclusions and Relevance
In this phase 3 randomized clinical trial, CCRT with S-1 was tolerable and provided significant benefits over RT alone in older patients with esophageal cancer.Trial Registration
ClinicalTrials.gov Identifier:NCT02813967Keywords:
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Objective To compare the long-term prognosis effects of non-esophagectomy and esophagectomy on patients with T1 stage esophageal cancer. Methods All esophageal cancer patients in the study were included from the National Surveillance Epidemiology and End Results (SEER) database between 2005-2015. These patients were classified into non-esophagectomy group and esophagectomy group according to therapy methods and were compared in terms of esophagus cancer specific survival (ECSS) and overall survival (OS) rates. Results A total of 591 patients with T1 stage esophageal cancer were enrolled in this study, including 212 non-esophagectomy patients and 111 esophagectomy patients in the T1a subgroup and 37 non-esophagectomy patients and 140 esophagectomy patients in the T1b subgroup. In all T1 stage esophageal cancer patients, there was no difference in the effect of non-esophagectomy and esophagectomy on postoperative OS, but postoperative ECSS in patients treated with non-esophagectomy was significantly better than those treated with esophagectomy. Cox proportional hazards regression model analysis showed that the risk factors affecting ECSS included race, primary site, tumor size, grade, and AJCC stage but factors affecting OS only include tumor size, grade, and AJCC stage in T1 stage patients. In the subgroup analysis, there was no difference in either ECSS or OS between the non-esophagectomy group and the esophagectomy group in T1a patients. However, in T1b patients, the OS after esophagectomy was considerably better than that of non-esophagectomy. Conclusions Non-esophagectomy, including a variety of non-invasive procedures, is a safe and available option for patients with T1a stage esophageal cancer. For some T1b esophageal cancer patients, esophagectomy cannot be replaced at present due to its diagnostic and therapeutic effect on lymph node metastasis.
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Abstract Correlations between preoperative antibody response and postoperative septic complications were examined in patients with esophageal cancer. Thirty‐three patients and 9 age‐matched controls were immunized with 23‐valent pneumococcal polysaccharide (PPS) vaccine, and serum anti‐PPS IgG, IgA, and IgM were measured. Of 28 patients undergoing transthoracic esophagectomy, 9 had postoperative septic complications (SCP) and 19 did not (SCN). Median titers of anti‐PPS IgG‐producing capacity were 158 ELISA units (EU) (interquartile range, 71‐1,862 EU) in the SCP group and 1,349 EU (interquartile range, 741‐2,95 1 EU) in the SCN group ( P = 0.01). No significant differences in anti‐PPS IgA and IgM were found between the two groups. These results indicated that low antibody response to polysaccharides is associated with the occurrence of postoperative septic complications in patients with esophageal cancer. Thus, a preoperative evaluation of antibody‐producing capacity may serve to predict these complications. © 1994 Wiley‐Liss, Inc.
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Since mucosal (T1a) esophageal cancer is well controlled by endoscopic treatment, chemoradiotherapy (CRTx) is not indicated. However, for a submucosal (T1b, N0) esophageal cancer, CRTx may be the first line of treatment, since it can provide a good response rate, with an excellent survival rate comparable to that after esophagectomy. Definitive CRTx is also in the first line of treatment for a T4 esophageal cancer, because there was no difference in the survival rate between CRTx with surgery and CRTx without surgery in our trial. Esophagectomy is indicated only for non-responders or recurrence-salvage surgery. For patients with a potentially-resectable (T2-T3) esophageal cancer, esophagectomy offered a longer survival rate than CRTx did, in our series. However, there remains controversy over the efficacy of CRTx for a T2-T3 esophageal cancer. It has been reported by the National Cancer Center Hospital East Group that definitive CRTx provided the same survival rate as esophagectomy. A prospective trial comparing the survival rate after esophagectomy and that after CRTx for a T2-T3 esophageal cancer is needed.
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Background: Esophagectomy offers the chance of cure for esophageal cancer, however, the optimal circumferential extent of surgery remains uncertain. En bloc esophagectomy (EBE) and total meso-esophagectomy (TME) have yielded inconsistent results. Therefore, the purpose of this study was to evaluate the surgical and oncological effects of EBE and TME on esophageal cancer patients.
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Definitive chemoradiotherapy has been demonstrated to offer a chance of cure for esophageal cancer as often as a radical esophagectomy. However, it is generally accepted that an esophagectomy remains the mainstay of treatment for patients with resectable esophageal cancer, while chemoradiotherapy is the standard for patients with medically inoperable or surgically unresectable esophageal cancer. The mortality rates and the 5-year survival rates after an esophagectomy were 29% and 4%, respectively, in an early extensive reviews involving 122 English papers on esophageal cancer surgery published between 1960 and 1979. The respective rates have improved to 6.7% and 27.9% in the most recent systematic reviews involving 312 papers published between 1990 and 2000. The overall survival at 5 years was 36.1% after esophagectomy in 11,642 patients between 1988 and 1997 in Japan. A 3-field lymphadenectomy involving the 3 anatomical compartments of the neck, mediastinum, and abdomen was introduced as an important component of a curative esophageal resection in the early 1980s in Japan, and has been reported to be effective for improving not only the staging accuracy, but also the long-term survival in patients with esophageal cancer, with the average 5-year survival rate being 40 to 60%. At present, 63% of all Japanese patients with esophageal cancer undergo an esophagectomy. Of these patients undergoing surgery, a 3-field and a conventional 2-field lymphadenectomy is performed in 35% and 33%, respectively. Alternatively, a transhiatal esophagectomy without a systematic lymphadenectomy has become one of the preferred types of surgery for patients with esophageal cancer in Western countries. An Appropriate Esophagectomy for Esophageal Cancer: A Lack of Evidence and a Growing Disparity between Western and Eastern Standards
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